• Is scleral depression a requirement for CPT code 92201


    Question: Is scleral depression a requirement for CPT code 92201? 


    Answer: Yes. CPT code 92201 Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (eg, for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral, as the description states, requires documentation and performance of scleral depression. If it is unwise to perform scleral depression, indicate the contraindication in the medical record.